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HomeMy WebLinkAboutApplication and WCWesv WoLtOod- Ply Saw L - TOWN OF YARMOUTH BOARD OF HEALTH ® APPLICATION FOR LICENSE/PERMIT - 2019 * Please complete form and attach all necessary documents by December 15, 2018. NOTE: ALL BUSINESSES "THLIOUOR LICENSES MUST RETURN FORMS BY NOVEMBER 15`''. Failure to do so will result in the return of your application packet. ESTABLISHMENT NAME: Com( LOCATION ADDRESS: 'l07 R MAILING ADDRESS: 8?1 E-MAIL ADDRESS: Ir, k.n c"k OWNER NAME: Cir fie_ X ID: TEL.4: 50 $. 4lb- 55.74-- 'Z4, C+ I CORPORATION NAME IF�BLE): G"ok,�75tatE� MANAGER'S NAME: d".2q 5j2 �O �r1n 111�w>aS TEL.#: 5769. 4164 5C'71 MAILING ADDRESS: S 'a vy2_ JtVeGbbn!�) POOL CERTIFICATIONS: The pool supervisor must be certified as a Pool Operator, as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. 1. 2. Pool operators must list a minimum of two employees currently certified in standard First Aid and Coml win tTC 2Oi9 Cardiopulmonary Resuscitation (CPR), having one certified employee on premises at all times. Please 1 st th C�" employees below and attach copies of their certifications to this form. The Health Department will not upast years' records. You must provide new copies and maintain a file at your place of business. HEALTH DEPT FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service Establishments. 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. HEIMLICI-I CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti -choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. RESTAURANT SEATING: TOTAL # LODGING: LICENSE REQUIRED FEE PERMIT # B&B $55 _INN $55 LODGE $55 FOOD SERVICE: LICENSE REQUIRED FEE PERMIT # 0-100 SEATS $125 >100 SEATS $200 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT # <50 sq. ft. $50 _<25,000 sq.ft. $150 NAME CHANGE: $15 4. OFFICE USE ONLY LICENSE REQUIRED FEE PERMIT # CABIN $55 CAMP $55 TRAILER PARK $105 LICENSE REQUIRED FEE PERMIT # _CONTINENTAL $35 COMMON VIC. $GO LICENSE REQUIRED FEE PERMIT # _MOTEL $110 _ SWIMMING POOL $110n WHIRLPOOL $I1Oea. LICENSE REQUIRED FEE PERMI # yXNON-PROFIT $30 WHOLESALE $80 —RESID. KITCHEN $80 LICENSE REQUIRED FEE PERMIT # LICENSE REQUIRED FEE PERMIT # >25,000 sq.ft. $285 VENDING -FOOD $25 —FROZEN DESSERT $40 _TOBACCO $110 AMOUNT DUE = S :3 /j O ti *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** O A- tl ' 61 c00 Vr ._.t) f� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6, the Town of Yarmouth is now required to hold issuance or renewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORKER'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short tenn occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty (30) days, and an aggregate of not more than ninety (90) days within any six (6) month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING: All swimming, wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening. PLEASE NOTE: People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas, total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swinnming pool must be drained or covered within seven (7) days of closing FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department, or from the Town's website at www.yarmouth.ma.us under Health Department, Downloadable Fonns. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OLiTSIDE CAFES: Outside cafes (i.e., outdoor seating with waiter/waitress service), must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking, preparation, or display of any food product by a retail or food service establishment is prohibited. TOBACCO PRODUCT PERMIT CAP A tobacco permit holder who has failed to renew his or her permit within thirty (30) days of the previous year's permit expiration date is considered an expired license. and the tobacco license cap is reduced. NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S) BY DECEMBER 15. 2018. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.). MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQUIRE A SITE PLAN. DATE: 9,.'J, I SIGNATURE: PRINT NAME & TITLE: 7►l S�L�✓te c5 J'7 0 - Rev. 10/21/18 CERTIFICATE OF LIABILITY INSURANCE DATE (M 1/901 YYY) IFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. rTC0`R IS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX EASTERN INS 233 WEST CENTRAL STREET (A/C, No, Ext): (A/C, No): E-MAIL NATICK, MA 01760 ADDRESS: 73KCD INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA INSURER B: CAPE COD CHILD DEVELOPMENT PROGRAM INC INSURER C: INSURER D: C/O HUMAN RESOURCES 83 PEARL STREET INSURER E: HYANNIS, MA 02601 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDMYYYY) (MMIDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE TO RENTED $ PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY [:] PROJECT 0 LOC PRODUCTS - COMP/OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS (Per person) BODILY INJURY $ (Per accident) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ (Per accident) UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS -MADE AGGREGATE $ $ DEDUCTIBLE RETENTION $ A WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY YIN UB -7H730332-18 10/15/2018 10/15/2019 X WC STATUTORY LIMITS OTHER E. L. EACH ACCIDENT $ 500,000 ANY PROPERITOR/PARTNER/EXECUTIVE rN7 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A E.L. DISEASE - EA EMPLOYEE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATION S/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION FALMOUTH HEALTH DEPARTMENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED ATTN: MALLORY BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 59 TOWN HALL SQUARE AUTHORIZED REPRESENT VE "V FALMOUTH, MA 02540 ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORPORATION. All rights reserved.